A Survey of Knowledge About and Perceived Barriers to Prostate Cancer Screening Among Medical Staff

AUTHORS

Javad Akbarizadeh 1 , Mahin Gheibizadeh 1 , * , Malek Fereidoonimoghadam 1 , Simin Jahani 1 , Amal Saki Malehi 2

1 Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran

2 Department of Biostatistics and Epidemiology, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran

How to Cite: Akbarizadeh J, Gheibizadeh M, Fereidoonimoghadam M, Jahani S, Saki Malehi A. A Survey of Knowledge About and Perceived Barriers to Prostate Cancer Screening Among Medical Staff, Jundishapur J Chronic Dis Care. 2016 ; 5(3):e31744. doi: 10.17795/jjcdc-31744.

ARTICLE INFORMATION

Jundishapur Journal of Chronic Disease Care: 5 (3); e31744
Published Online: April 25, 2016
Article Type: Research Article
Received: July 23, 2015
Revised: August 19, 2015
Accepted: August 29, 2015
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Abstract

Background: Prostate cancer is the most common cancer among men and the second leading cause of deaths from cancer. Results of previous studies indicate the effectiveness of screening and early detection in reducing mortality from this disease.

Objectives: The purpose of this study was to survey the knowledge about prostate cancer and perceived barriers to prostate cancer screening among medical staff of two universities in Ahvaz, Iran.

Materials and Methods: This cross-sectional descriptive study was performed on 120 employees over 40 years old at Ahvaz Jundishapur University of Medical Sciences and Shahid Chamran University of Ahvaz, who were selected by using simple random sampling. The data collection tool was a researcher-created questionnaire based on the study of texts and other studies. Data analysis was performed using SPSS software and through analytical methods including descriptive and inferential statistics.

Results: The most common barriers to screening for prostate cancer were a lack of knowledge about where to go for tests and how screening tests are done (70.8%), a lack of emphasis on screening tests (59.1%), and a fear of thinking about the disease (50%). Results showed that there was no significant relationship between doing the serum antigen test and having knowledge regarding prostate cancer. But there was a significant association between prostate cancer screening and perceived barriers (P = 0.001).

Conclusions: Results showed that whereas knowledge by itself cannot guarantee men’s participation in prostate cancer screenings, perceived barriers can play an important role in discouraging men from cancer screening participation. Therefore, designing programs to address these barriers is very important.

Keywords

Prostate Cancer Screening Prostate Antigen Serum (PSA) Test Barriers

Copyright © 2016, Ahvaz Jundishapur University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Prostate cancer is one of the major health problems in the world (1), has a significant impact on patients’ and their caregivers’ quality of life, and imposes heavy costs on them (2). It is the second most common cancer and the second leading cause of death from cancer among the male population worldwide (3, 4). The peak incidence of disease is in people between the ages of 60 and 70 (2). The incidence of prostate cancer in developed countries is six times higher than in less developed countries (5). Although not many studies on prostate cancer are conducted in Asia, including Iran, it continues to be one of the main causes of death in Iran (6). According to the cancer statistical center of Iran, in 2009 prostate cancer had an age-standardized incidence rate (ASR) of 12.59 per 100,00 people, making it the third most prevalent cancer among men in Iran (7). In Khuzestan province, prostate cancer also ranked as the third most common cancer among men, and accounts for about 8% of all cancers in this region. The reported ASR in this region is 7.64 per 100,000 people (8).

The causes of prostate cancer are not completely understood, but it is believed that aging, positive family history, and race (e.g. African-American race) are among the relevant risk factors (9). The nature of prostate cancer is such that as long as there is no local progression or metastasis to other parts of the body, it usually does not cause any symptoms (10), and on presentation of symptoms, the disease usually has run its course. Therefore, early detection of the disease in its early stages can be an effective measure in reducing its mortality rate in asymptomatic men (11, 12), and creates an opportunity to use effective and inexpensive treatment methods (13). The detection phase is an important factor in the expression of the cancer-related survival rate. The five-year survival rate in men with localized (i.e., without metastasis) prostate cancer is almost 100%, while the rate among men with prostate cancer that has metastasized to other parts of the body is only 31% (11).

Expansion of prostate cancer screening programs will certainly lead to increased diagnosis in the early stages, and therefore to treatment (12). The effectiveness of prostate cancer screening methods to identify the disease and reduce mortality from it has been proven, as various studies have shown reduced mortality from prostate cancer through screening programs (14). Early detection and screening of prostate cancer are done using a prostate antigen serum (PSA) test and a rectal examination (DRE) (12). Prostate antigen is a serine protease that is produced by the prostate epithelial cells and can be found in the blood serum. In a rectal examination, the approximate size of the prostate is determined and any abnormal growths can be detected (15). In an analysis of data collected from seven European countries, a significant reduction in mortality from prostate cancer following a PSA test was observed after a period of about nine years (16); in addition, a study by Hugosson et al. in 2010 (17) suggests a decrease in mortality rate following prostate cancer screening tests.

Despite the importance of early detection in increasing life expectancy, the results of the studies suggest that men are not willing to take screening test procedures. These include studies of Filipino men living in Hawaii, African-American men, and men living in the Caribbean; the results indicate low participation of these groups in screening programs, even though their incidence of prostate cancer is relatively high (11, 18). In addition, men with few symptoms are usually not willing to see a doctor, and see the doctor only when their condition becomes severe (19). The reason for low participation in the screening program is still not quite clear, but it may be associated with low socio-economic status, lack of insurance coverage for screening, lack of knowledge about prostate cancer, and lack of physician recommendations for screening (20-23).

There are differences in the recommended time for prostate cancer screening. The American urological association has recommended prostate cancer screening for men 40 years or older with a life expectancy of at least 10 years (24), while the United States prostate cancer foundation (PCF) has recommended screening for men over 50 years with a life expectancy of at least 10 years (11). The preventive services task force of America (USPSTF) has stated that screening in people 75 years and older should not be performed due to the higher risks and lower benefits of screening (25). Therefore, men aged between 40 and 75 years are the most suitable target group for prostate cancer screening.

According to the above-mentioned studies, understanding people’s knowledge of a disease and why so many at-risk people ignore screening behaviors is very important. Several different models have identified relevant factors. One of these models is the health belief model (HBM), which is designed to understand why people who are at risk of a disease are not willing to take diagnostic procedures (26). The model consists of six constructs affecting health behaviors, including perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action (27). In this study, the construct of perceived barriers is used to identify barriers associated with screening behavior.

HBM been used as a predictor of behavior in diseases such as skin cancer (28), colorectal cancer (29), breast cancer (30), and cervical cancer (31) in different countries. This model was used in Iran for some cancers such as breast cancer (32), cervical cancer (33), and colorectal cancer (34), and all the studies emphasized the importance of applying the model in predicting behaviors.

2. Objectives

This study aimed to survey the knowledge of and perceived barriers to prostate cancer screening among the staff of Ahvaz Jundishapur University of Medical Sciences and Shahid Chamran University of Ahvaz.

3. Materials and Methods

This is a cross-sectional descriptive study conducted from January 2015 to June 2015 on male employees over 40 years old working in Ahvaz Jundishapur University of Medical Sciences or Shahid Chamran University of Ahvaz. After obtaining the necessary permits, a list of male employees (including workers, mentors and faculty members) aged over 40 was prepared. The sample size estimate was obtained based on 80% power for detecting a significant relationship of 0.37 with a significance level of α = 0.05. By assuming a 10% loss to the follow-up rate, we would need to randomize 60 participants at each university. The samples were selected using simple random sampling. Inclusion criteria were willingness to participate in the study, completion of the written informed consent, no history of prostate cancer, and being 40 - 75 years old. The exclusion criterion was an incomplete response to the questionnaire. The sample size formula is:

Equation 1.

3.1. Data Collection Tools

The data collection tool was a researcher-created questionnaire that was prepared based on studying texts and previous studies. The questionnaire’s content validity was determined using CVI and CVR, considering the cut-off point of CVR > 0.62 and CVI > 0.79 that was approved by 10 professors of the school of nursing and midwifery and school of health sciences in Ahvaz Jundishapur University of Medical Sciences. The reliability of the questionnaire was calculated using Cronbach’s alpha, which was calculated as 0.72 and 0.79 for the questions related to knowledge and perceived barriers, respectively.

The questionnaire consists of three parts. The first part of the questionnaire includes eight questions primarily related to demographic factors (age, marital status, place of work, income, occupation, education, history of prostate cancer in first degree relatives, and history of PSA testing). The second part included 12 questions related to knowledge about prostate cancer, and the third part of the questionnaire had 10 questions related to perceived barriers to screening. To score the knowledge part of the questionnaire, the correct answer was given one point, while the wrong and “I do not know” answers were given a score of zero. Therefore, the part 2 total score ranged between zero and 12. For scoring the perceived barriers questions, a five-option Likert scale (agree = 1 point; somewhat agree = 2 points; I have no opinion = 3 points; somewhat disagree = 4 points; disagree =5 point) was used, with the total score ranging between 10 and 50.

3.2. Data Analysis

The data were analyzed using SPSS statistical software as well as descriptive and inferential statistics indexes. A chi-square test was used to determine the relationship between education level and PSA testing, the relationship between income and PSA testing, and the relationship between knowledge and perceived barriers to performing PSA testing.

3.3. Ethical Considerations

This study was approved by the ethics committee of Ahvaz Jundishapur University of Medical Sciences (ajums.REC.1393.371). In this study, the researchers have been trained on ethical issues such as respect for the right to participate voluntarily, obtaining consent from potential participants to participate in the project, and informing the participants of the purpose of the study.

4. Results

According to the survey results, the average and standard deviation of participants’ age was 49.69 ± 6.88, most of them were married (94.2%), and 38.3% had a diploma certificate. Other demographic data are presented in Table 1.

Table 1. The Demographics Characteristics of the Participants in the Study
Demographic VariablesNo. (%)
Age, y
40 - 4978 (65)
50 - 5935 (29.7)
60 - 757 (5.83)
Education
Diploma46 (38.3)
Associate degree8 (6.7)
BSc16 (13.3)
MSc10 (8.3)
PhD40 (33)
Job
Worker18 (15)
Employee54 (45)
Faculty member/lecturer34 (2.5)
Science committee5 (17.5)
Income, million
< 123 (19.16)
1 - 249 (40.8)
2 - 3.524 (1.6)
> 3.56 (38.3)

Among the men who participated in the study, 17.5% had a family history of prostate cancer, and 75.8% of them had not done a PSA test at the time of the study. The mean and standard deviation of the knowledge was 6.38 ± 2.5, with only 22.5% of the participants having a high level of knowledge about prostate cancer and screening tests. In regard to the sources of information about prostate cancer, 55.8% and 60.8% of respondents said that they have received information through media and friends, respectively. In addition, 17.6% of them reported that their physician had advised them to do the screening test, while only 19.3% of respondents said that family recommended them to take the test. Results showed that there was no significant relationship between knowledge and PSA testing, but there was a significant relationship between education level and PSA testing (P = 0.046), as well as between income and PSA testing (P = 0.034). There was also a significant relationship between the construct of perceived barriers and PSA testing (P = 0.001).

5. Discussion

The purpose of this study was to evaluate knowledge and perceived barriers to prostate cancer screening among the staff of Ahvaz Jundishapur University of Medical Sciences and Shahid Chamran University of Ahvaz. This study showed that most people did not have good knowledge about prostate cancer screening methods. These results are consistent with the results of Ghodsbin et al. (35) and the results of Gozum and Capik (36). In addition, the study of Ford et al. (37) reveals a low level of knowledge in the field of prostate cancer screening, which indicates a need for training about this disease in order to improve men’s knowledge about the most common type of cancer, so that their participation in screening programs can be improved and the disease’s incidence can be reduced.

Most participants in this study acquired information about prostate cancer through their friends, which is in accordance with the findings of Ferrante et al. (38). More than half of the participants in the study mentioned mass media as their main source of information regarding prostate cancer, which is consistent with the results of the Nakandi et al. study (4). Given the role of mass media, HBM model principles are useful for designing training programs and encouraging health messages through the media, so that a greater percentage of men can be encouraged to practice prostate cancer screening.

The findings of this study suggest that a small percentage of people have done the PSA test, as is consistent with the results of the Ghodsbin et al. study (35). This matter requires further pursuit by the health system in order to increase men’s participation in screening programs. In this study there was a significant relationship between age and PSA testing, so that with increasing age, PSA testing was increased, which is consistent with the Lehto et al. (39) study. Furthermore, there was a significant relationship between income and education level and PSA tests, so that PSA testing in individuals with higher income and education was higher, which is similar to the results of the Ibrayev et al. (40) study.

Similarly, the results indicate that there is no significant relationship between knowledge and doing the PSA test, which is consistent with the results of Oranusi et al. (2). These results suggest that knowledge alone has no decisive role in increasing men’s participation in screening programs, and barriers other than lack of knowledge play a role in low male participation in prostate cancer screening. Indeed, the results show a significant relationship between perceived barriers and the PSA test. As mentioned earlier, perceived barriers is a one of the HBM model constructs that has predictive power for health behaviors, and in this study it is used for determining the effective factors in the prostate cancer screening behaviors. These results are also consistent with the findings of Oliver et al. (41). Participants in the study mentioned a lack of knowledge of where to go and how to do screening tests, a lack of emphasis on the screening tests, and a fear of thinking about the disease as the most common barriers to the prostate cancer screening. These results are consistent with the results of some previous studies (11, 13, 41).

This study implies that knowledge about prostate cancer and participation in cancer screening is not appropriate despite the high prevalence of the disease among the male population. This problem requires taking measures to increase knowledge of prostate cancer among men, so a suitable condition for screening can be created. Since there is a significant relationship between perceived barriers and prostate cancer screening behaviors, some plans can be designed to reduce these barriers and encourage men to do the screening tests.

To our knowledge there was little evidence regarding prostate cancer knowledge and perceived barriers to prostate cancer screening in Iranian society. Therefore, this study revealed valuable evidence in this regard. Selecting a special population (university employees) does limit its generalizability to all men in the community. Thus, large-scale studies with samples selected from all parts of the society are recommended, to obtain more generalizable results for macro-planning in the health sector.

Acknowledgements

Footnotes

References

  • 1.

    Alghamidi IG, Hussain II, Alghamdi MS, El-Sheemy MA. The incidence rate of prostate cancer in Saudi Arabia: an observational descriptive epidemiological analysis of data from the Saudi Cancer Registry 2001-2008. Hematol Oncol Stem Cell Ther. 2014; 7(1) : 18 -26 [DOI][PubMed]

  • 2.

    Oranusi CK, Mbieri UT, Oranusi IO, Nwofor AME. Prostate cancer awareness and screening among male public servants in Anambra State, Nigeria. Afr J Urol. 2012; 18(2) : 72 -4 [DOI]

  • 3.

    Mazdak H, Mazdak M, Jamali L, Keshteli AH. Determination of prostate cancer risk factors in Isfahan, Iran: a case-control study. Med Arh. 2012; 66(1) : 45 -8 [PubMed]

  • 4.

    Nakandi H, Kirabo M, Semugabo C, Kittengo A, Kitayimbwa P, Kalungi S, et al. Knowledge, attitudes and practices of Ugandan men regarding prostate cancer. Afr J Urol. 2013; 19(4) : 165 -70 [DOI][PubMed]

  • 5.

    Shafique K, McLoone P, Qureshi K, Leung H, Hart C, Morrison DS. Cholesterol and the risk of grade-specific prostate cancer incidence: evidence from two large prospective cohort studies with up to 37 years' follow up. BMC Cancer. 2012; 12 : 25 [DOI][PubMed]

  • 6.

    Hosseini M, SeyedAlinaghi S, Mahmoudi M, McFarland W. A case-control study of risk factors for prostate cancer in Iran. Acta Med Iran. 2010; 48(1) : 61 -6 [PubMed]

  • 7.

    Etemadi K, Mehdigouya M, Ramezanidaryia Sari R, Modiriyan M, Partovipoor E, Arjmandpoor M. Iran Cancer Report 2010, [in Persian]. 2014;

  • 8.

    Talaiezadeh A, Tabesh H, Sattari A, Ebrahimi S. Cancer incidence in southwest of iran: first report from khuzestan population-based cancer registry, 2002-2009. Asian Pac J Cancer Prev. 2013; 14(12) : 7517 -22 [PubMed]

  • 9.

    So WK, Choi KC, Tang WP, Lee PC, Shiu AT, Ho SS, et al. Uptake of prostate cancer screening and associated factors among Chinese men aged 50 or more: a population-based survey. Cancer Biol Med. 2014; 11(1) : 56 -63 [DOI][PubMed]

  • 10.

    Madu CO, Lu Y. Novel diagnostic biomarkers for prostate cancer. J Cancer. 2010; 1 : 150 -77 [PubMed]

  • 11.

    Conde FA, Landier W, Ishida D, Bell R, Cuaresma CF, Misola J. Barriers and facilitators of prostate cancer screening among Filipino men in Hawaii. Oncol Nurs Forum. 2011; 38(2) : 227 -33 [DOI][PubMed]

  • 12.

    Smith RA, Manassaram-Baptiste D, Brooks D, Cokkinides V, Doroshenk M, Saslow D, et al. Cancer screening in the United States, 2014: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2014; 64(1) : 30 -51 [DOI][PubMed]

  • 13.

    Paiva EP, Motta MC, Griep RH. Barriers related to screening examinations for prostate cancer. Rev Lat Am Enfermagem. 2011; 19(1) : 73 -80 [PubMed]

  • 14.

    Teishima J, Maruyama S, Mochizuki H, Oka K, Ikeda K, Goto K, et al. Prostate cancer detection by prostate-specific antigen-based screening in the Japanese Hiroshima area shows early stage, low-grade, and low rate of cancer-specific death compared with clinical detection. Can Urol Assoc J. 2014; 8(5-6) -32 [DOI][PubMed]

  • 15.

    Winterich JA, Grzywacz JG, Quandt SA, Clark PE, Miller DP, Acuna J, et al. Men's knowledge and beliefs about prostate cancer: education, race, and screening status. Ethn Dis. 2009; 19(2) : 199 -203 [PubMed]

  • 16.

    Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009; 360(13) : 1320 -8 [DOI][PubMed]

  • 17.

    Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010; 11(8) : 725 -32 [DOI][PubMed]

  • 18.

    Lee DJ, Consedine NS, Spencer BA. Barriers and facilitators to digital rectal examination screening among African-American and African-Caribbean men. Urology. 2011; 77(4) : 891 -8 [DOI][PubMed]

  • 19.

    Sayer GP, Britt H. Sex differences in morbidity: a case of discrimination in general practice. Soc Sci Med. 1996; 42(2) : 257 -64 [PubMed]

  • 20.

    Gonzalez JR, Consedine NS, McKiernan JM, Spencer BA. Barriers to the initiation and maintenance of prostate specific antigen screening in Black American and Afro-Caribbean men. J Urol. 2008; 180(6) : 2403 -8 [DOI][PubMed]

  • 21.

    Steele CB, Miller DS, Maylahn C, Uhler RJ, Baker CT. Knowledge, attitudes, and screening practices among older men regarding prostate cancer. Am J Public Health. 2000; 90(10) : 1595 -600 [PubMed]

  • 22.

    Wilkinson S, List M, Sinner M, Dai L, Chodak G. Educating African-American men about prostate cancer: impact on awareness and knowledge. Urology. 2003; 61(2) : 308 -13 [PubMed]

  • 23.

    Merrill RM. Demographics and health-related factors of men receiving prostate-specific antigen screening in Utah. Prev Med. 2001; 33(6) : 646 -52 [DOI][PubMed]

  • 24.

    Greene KL, Albertsen PC, Babaian RJ, Carter HB, Gann PH, Han M, et al. Prostate specific antigen best practice statement: 2009 update. J Urol. 2009; 182(5) : 2232 -41 [DOI][PubMed]

  • 25.

    Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008; 149(3) : 185 -91 [PubMed]

  • 26.

    Tavassoli E, Reisi M, Javadzad SH, Gharli Pour Z, Gilasi HR, Ghasemi S, et al. The effect of education on the improvement of fruits and vegetables consumption aiming to preventing colorectal cancer. Gastroenterol Hepatol Bed Bench. 2014; 7(2) : 94 -100 [PubMed]

  • 27.

    Bayat F, Shojaeezadeh D, Baikpour M, Heshmat R, Baikpour M, Hosseini M. The effects of education based on extended health belief model in type 2 diabetic patients: a randomized controlled trial. J Diabetes Metab Disord. 2013; 12(1) : 45 [DOI][PubMed]

  • 28.

    Nahar VK, Ford MA, Hallam JS, Bass MA, Hutcheson A, Vice MA. Skin Cancer Knowledge, Beliefs, Self-Efficacy, and Preventative Behaviors among North Mississippi Landscapers. Dermatol Res Pract. 2013; 2013 : 496913 [DOI][PubMed]

  • 29.

    Wong RK, Wong ML, Chan YH, Feng Z, Wai CT, Yeoh KG. Gender differences in predictors of colorectal cancer screening uptake: a national cross sectional study based on the health belief model. BMC Public Health. 2013; 13 : 677 [DOI][PubMed]

  • 30.

    Tuzcu A, Bahar Z. Barriers and facilitators to breast cancer screening among migrant women within Turkey. J Transcult Nurs. 2015; 26(1) : 47 -56 [DOI][PubMed]

  • 31.

    Reis N, Bebis H, Kose S, Sis A, Engin R, Yavan T. Knowledge, behavior and beliefs related to cervical cancer and screening among Turkish women. Asian Pac J Cancer Prev. 2012; 13(4) : 1463 -70 [PubMed]

  • 32.

    Rezaeian M, Sharifirad G, Mostafavi F, Moodi M, Abbasi MH. The effects of breast cancer educational intervention on knowledge and health beliefs of women 40 years and older, Isfahan, Iran. J Educ Health Promot. 2014; 3 : 43 [DOI][PubMed]

  • 33.

    Shojaeizadeh D, Hashemi SZ, Moeini B, Poorolajal J. The Effect of Educational Program on Increasing Cervical Cancer Screening Behavior among Women in Hamadan, Iran: Applying Health Belief Model. J Res Health Sci. 2011; 11(1) : 20 -5 [PubMed]

  • 34.

    Javadzade SH, Reisi M, Mostafavi F, Hasanzade A, Shahnazi H, Sharifirad G. Factors associated with the fecal occult blood testing for colorectal cancer screening based on health belief model structures in moderate risk individuals, Isfahan, 2011. J Educ Health Promot. 2012; 1 : 18 [DOI][PubMed]

  • 35.

    Ghodsbin F, Zare M, Jahanbin I, Ariafar A, Keshavarzi S. A Survey of the Knowledge and Beliefs of Retired Men about Prostate Cancer Screening Based on Health Belief Model. Int J Community Based Nurs Midwifery. 2014; 2(4) : 279 -85 [PubMed]

  • 36.

    Gozum S, Capik C. P82 Factors affecting participation in prostate cancer screenings: demographic characteristics, and level of knowledge and health beliefs about prostate cancer. Eur J Oncol Nurs. 2010; 14[DOI]

  • 37.

    Ford ME, Vernon SW, Havstad SL, Thomas SA, Davis SD. Factors influencing behavioral intention regarding prostate cancer screening among older African-American men. J Natl Med Assoc. 2006; 98(4) : 505 -14 [PubMed]

  • 38.

    Ferrante JM, Shaw EK, Scott JG. Factors influencing men's decisions regarding prostate cancer screening: a qualitative study. J Community Health. 2011; 36(5) : 839 -44 [DOI][PubMed]

  • 39.

    Lehto RH, Song L, Stein KF, Coleman-Burns P. Factors influencing prostate cancer screening in African American men. West J Nurs Res. 2010; 32(6) : 779 -93 [DOI][PubMed]

  • 40.

    Ibrayev Y, Oda K, Fraser GE, Knutsen SF. Utilization of prostate cancer screening according to dietary patterns and other demographic variables. The adventist health study-2. J Cancer. 2013; 4(5) : 416 -26 [DOI][PubMed]

  • 41.

    Oliver JS, Grindel CG, DeCoster J, Ford CD, Martin MY. Benefits, barriers, sources of influence, and prostate cancer screening among rural men. Public Health Nurs. 2011; 28(6) : 515 -22 [DOI][PubMed]

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